Hysterosalpingogram (HSG): What the Test Shows and What to Expect
Key Takeaways
HSG uses X-rays to show the womb and whether dye passes through the tubes. It does not test all tube functions, and pain relief should be planned before the test. Fever or worsening pelvic pain afterwards needs prompt care.
Key evidence: ASRM — HSG patient information ASRM — Fertility evaluation (2026) ACOG — Pain management (2025)
On this page
- What an HSG is — and what it is not
- When in your cycle the test is done
- What actually happens during the test
- Does an HSG hurt?
- What an HSG can show — and what it cannot
- Dr. Aksoy’s Approach
- Can the test itself improve your chances?
- What an abnormal result usually means next
- Frequently Asked Questions for Dr. Aksoy
- FAQ
- Sources
What an HSG is — and what it is not
A hysterosalpingogram is an X-ray test. Dye passes through the cervix into the womb. A short series of images then shows where it goes. The dye should fill the womb, travel through both tubes and spill into the abdomen. HSG stands for hysterosalpingography — hystero for womb, salpingo for tube and graphy for imaging.
An HSG is a diagnostic test, not a treatment. It produces images of the uterine cavity and fallopian tubes; it does not repair a blockage. Tubal flushing may affect the chance of conception in a selected group, as discussed below, but that is not the main reason for ordering the test.
An HSG looks inside two spaces: the cavity of the uterus, and the channel inside each tube. It does not show the outside of the tubes, the ovaries, or the pelvic lining.
When in your cycle the test is done
HSG is usually booked after your period ends and before ovulation. The centre will confirm the exact day for your cycle; irregular periods need an individual plan. ASRM patient information.
Before the appointment, tell the team if pregnancy is possible, you have symptoms of a pelvic infection, or you have reacted to contrast before. HSG should not be done if pregnancy is suspected, and the oil-based contrast product information also rules it out during acute pelvic inflammation. ASRM patient information and Lipiodol product information. Timing the test early in the cycle does not replace checking whether pregnancy is possible. Follow the centre’s instructions about sex or contraception before the test.
Also mention previous pelvic infections, which are linked to a higher risk of infection after HSG, as well as thyroid disease and your medicines. ASRM patient information. Your team decides whether antibiotics are appropriate in your case; they are not needed automatically.
What actually happens during the test
The imaging usually takes only a few minutes. Allow longer for preparation, positioning and recovery. ASRM procedure guide.
You lie on an X-ray table. A speculum is placed in the vagina, the cervix is cleaned, and a thin tube is passed through it. The team slowly injects contrast, a liquid that shows up on X-rays. Images track its passage through the womb and tubes.
Mild cramps, light spotting and some fluid leaking afterwards can occur; spotting usually lasts a day or two. Contact the team promptly for increasing pelvic pain or fever in the first days, heavy bleeding, feeling faint, or a rash, itching or swelling. ASRM: risks and recovery. Unusual or foul-smelling discharge is another reason to call. Contrast can also reach the bloodstream, and the product information warns of rare but serious lung or brain embolic complications in the hours afterwards. Chest pain, cough, breathlessness, light-headedness, confusion or a severe headache after the test, and any sign of a severe allergic reaction, need emergency care. Lipiodol product information and ESUR.
Does an HSG hurt?
HSG can be painful, and the intensity varies. Pain often peaks as contrast enters and stretches the womb. Discuss pain relief before the appointment, especially if a previous examination was painful or you feel anxious. Babandi trial and ACOG pain guidance.
A cream applied to the cervix may reduce pain from handling the cervix. This is different from an injection of local anaesthetic. The benefit depends on the technique and stage of the procedure. ACOG 2025.
Older trials did not show a clear benefit from routine oral non-opioid painkillers during HSG. That is a limit of the evidence, not a reason to stop or change a pain-relief plan agreed with your clinician. Intravenous opioids may help, but their side effects and recovery needs must be considered. Cochrane pain review. ASRM’s patient sheet suggests taking a period-pain medicine such as ibuprofen beforehand. The trials above did not show a clear average benefit, so the plan is individual: ask your clinician what they recommend. ASRM patient information.
Evidence detail: pain scores and pain relief
In the Babandi trial, average pain scores during injection were about 5–7 out of 10 across the three study groups. These are trial averages, not a prediction of your pain. Babandi 2021.
The 2015 Cochrane review included 23 trials and 1,272 women. Oral non-opioid painkillers showed no clear reduction during the procedure (mean difference −0.13, 95% CI −0.48 to 0.23; 3 studies, 133 women; low-quality evidence). Topical anaesthetic showed a modest reduction (mean difference −0.63, 95% CI −1.06 to −0.19; 9 studies, 613 women; low-quality evidence). Cochrane 2015.
What an HSG can show — and what it cannot
HSG shows whether contrast passes through the tubes. It does not test every part of their function. An apparent blockage near the womb can be caused by a temporary spasm and may need confirmation. ASRM 2026.
| What you want to know | How well HSG answers it |
|---|---|
| Is a tube blocked? | It can show an apparent blockage; a finding near the womb may need confirmation |
| Are the tubes working normally? | It shows passage of contrast, not every function of the tubes |
| Is there scarring around the tubes? | HSG is not reliable for this |
| Is the uterine cavity an abnormal shape? | It outlines the cavity; a suspected abnormality may need ultrasound or MRI |
| Is there endometriosis? | HSG cannot diagnose or exclude it |
Endometriosis often affects tissue outside the spaces seen on HSG. ASRM’s patient sheet states that HSG is not designed to diagnose endometriosis. ASRM patient information. In women without symptoms who have a normal pelvic ultrasound and a normal HSG, ASRM estimates the likelihood of pelvic endometriosis at 2% to 23%. ASRM 2026.
Contrast ultrasound, called HyCoSy, is another way to assess whether the tubes are open. ASRM describes comparable diagnostic accuracy for HyCoSy and HSG. Laparoscopy is not used routinely just to check tube patency. ASRM 2026.
Evidence detail: why test accuracy varies
A 1995 review included 20 studies and 4,179 women. In the subset where HSG and laparoscopy were assessed independently, estimated sensitivity was 0.65 and specificity 0.83 for tubal patency. These describe agreement with a reference test in those studies, not the chance that an individual patient’s tubes are healthy. Other studies have produced different estimates; the figures are not a fixed performance rating for every HSG. Swart 1995 and ASRM 2026.
Dr. Aksoy’s Approach
A normal HSG shows that dye passes through the channel inside the tube. It does not prove that the tube works well. The fringed end may not collect the egg, the tiny hairs inside may not move well, or fine scars may sit around the tube. HSG can also miss mild endometriosis. That is why I do not read the word “normal” on its own.
I accept a normal HSG when the history does not point to disease in the tubes or pelvis. This means no past pelvic infection or chlamydia, ectopic pregnancy or pelvic surgery. There should also be no marked period pain, pain during sex or ovarian endometrioma. The images must be clear, with dye spilling quickly and freely from both tubes.
I investigate further only when the answer could change treatment. Delayed or loculated spill, a suspected hydrosalpinx, or a strong history of endometriosis or adhesions would prompt me to look further. By contrast, for an older patient or one with low ovarian reserve, a minor finding may not change the plan. In that situation, I would rather move to IVF than spend months on diagnostic laparoscopy.
This clinical input was recorded on 18 August 2026. For the current guideline context, see ASRM 2026.
In my practice we use water-based contrast. In my experience, few centres use oil-based contrast now. If you are offered oil-based contrast elsewhere, the thyroid and other precautions still apply. Dr. Aksoy gave this answer on 1 November 2026.
Can the test itself improve your chances?
Flushing the tubes with oil-based contrast may improve the chance of pregnancy in selected women. It does not repair every blocked tube, and a benefit before IVF embryo transfer has not been established. H2Oil trial.
The H2Oil trial studied women younger than 39 who ovulated and had a low risk of tubal disease, without severe male-factor infertility. They were initially offered time to conceive naturally or intrauterine insemination. Its results do not apply automatically to all patients. H2Oil population. The follow-up analysis in that paper was funded by Guerbet, the manufacturer of Lipiodol; the original trial was funded by two Amsterdam academic institutions.
Oil-based contrast also carries a substantial iodine load. ESUR recommends checking thyroid function before its use and monitoring it for up to six months afterwards. Discuss the follow-up plan with the team, especially if you have thyroid disease or become pregnant. ESUR 2024. In the H2Oil2 preprint, thyroid dysfunction was recorded in 75 of 299 women in the oil group and 7 of 292 in the water group (25.1% versus 2.4%); this is unreviewed preprint data. H2Oil2 preprint. The UK product information for Lipiodol lists hypersensitivity, overt hyperthyroidism, recent bleeding or injury, pregnancy, acute pelvic inflammation, marked cervical erosion, endocervicitis, uterine bleeding and the 30 days after curettage or conisation as contraindications; local labelling may differ. Lipiodol product information. Oil-based contrast is absorbed slowly and can stay in the abdomen for a long time. ESUR describes a greater inflammatory effect on the peritoneum than with water-based contrast, with unknown clinical consequences, and advises caution. ESUR.
Contrast can enter blood or lymph vessels during HSG; this is called intravasation. Most reported cases have no embolic symptoms, but rare serious complications have been described. The Lipiodol product information specifies slow injection under X-ray monitoring, with an immediate stop if intravasation is suspected, and says to stop if the patient develops excessive discomfort. ESUR lists excessive injection pressure or volume among the factors that favour intravasation. Lipiodol product information and ESUR.
Evidence detail: fertility outcomes and thyroid findings
The 2020 Cochrane review included 15 trials and 3,864 women across several comparisons. Oil-based contrast may increase the odds of live birth compared with no intervention (odds ratio 3.27, 95% CI 1.57 to 6.85; 3 trials, 204 women; low-quality evidence). Compared with water-based contrast, it probably increases asymptomatic intravasation (odds ratio 5.00, 95% CI 2.25 to 11.12; 4 trials, 1,912 women; moderate-quality evidence). The ESUR review instead states that intravasation occurs in similar amounts with both contrasts, although a Dutch survey it cites found more with oil, so the sources differ on this point. Cochrane tubal flushing and ESUR.
H2Oil assigned 1,119 women to the two groups by chance in 27 Dutch hospitals. Ongoing pregnancy from conception within six months was 39.7% with oil-based contrast versus 29.1% with water-based contrast. Live birth from these pregnancies was 38.8% versus 28.1% (rate ratio 1.38, 95% CI 1.17–1.64). An ongoing pregnancy is one that continues beyond the study’s specified early stage; it is not the same outcome as a baby being born alive. Reported adverse event rates were low and similar between groups. A small minority had IVF or ICSI during follow-up, although IVF was not the planned pathway. Dreyer 2017.
The June 2026 H2Oil2 preprint studied 932 women aged 39 or older, with ovulation disorders, or at high risk of tubal disease. Live birth was 23.5% versus 21.5%; adjusted hazard ratio 1.18 (95% CI 0.89–1.57). No clear benefit was shown. Thyroid dysfunction was reported in 75 of 299 women in the oil group and 7 of 292 in the water group (25.1% versus 2.4%; relative risk 10.64, CI 4.96 to 22.8); the abstract does not say when or how it was tested. This does not prove the two options are equivalent, and the report is a preprint, not a peer-reviewed final publication. H2Oil2 preprint. The trial design is described in the peer-reviewed study protocol. The trial was funded by ZonMW, a Dutch health research funder, with additional funding from Guerbet, the manufacturer of Lipiodol.
In a study of 70 pregnant women exposed to oil-based HSG before conception, 38 had excess iodine. Of these 38, 25 had clinical or subclinical hypothyroidism and two had thyrotoxicosis. Subclinical hypothyroidism is defined by blood-test results; symptoms alone do not define it. No thyroid dysfunction was detected in the offspring studied. Among the 38, four pregnancies ended in premature birth, abnormal fetal karyotype, miscarriage or a neonatal heart defect; with no comparison group, these cannot be attributed to the contrast. This selected group cannot provide a general complication rate for all women having HSG. Li 2021.
The UK Lipiodol product information specifies slow injection in 2 mL increments under fluoroscopic control until tubal patency is shown, and stopping immediately if intravasation is suspected or confirmed. It also advises keeping the dose as low as possible to reduce the risk of thyroid dysfunction. Lipiodol product information.
What an abnormal result usually means next
An abnormal HSG is usually the start of a more specific assessment.
If one or both tubes do not fill, the next question is whether this reflects a true blockage, spasm on the day, or disease further along the tube. When the apparent block is at the point where the tube meets the uterus, repeat imaging or selective tubal cannulation — passing a fine catheter into the tube — may be considered before laparoscopy. ASRM tubal surgery.
If a tube appears dilated and does not spill, the finding may be a hydrosalpinx. A communicating hydrosalpinx can reduce IVF pregnancy rates, so it may need treatment before embryo transfer. ASRM tubal surgery. If there has been a previous pelvic infection, salpingitis may explain the damage seen on the images.
Laparoscopy is not recommended routinely for fertility assessment. ASRM reserves it for suspected pelvic disease, such as endometriosis or a previous pelvic infection or operation, for an abnormal HSG, or for another specific reason such as severe period pain. If surgery is already planned, it can also check tube patency and treat adhesions. ASRM 2026.
Hysteroscopy is not an alternative to HSG. It assesses the uterine cavity, not the outside of the tubes or the pelvis. It is used when ultrasound or HSG suggests a cavity abnormality, when there is abnormal bleeding, or when intrauterine surgery is needed.
Bring the original images or report to any new consultation. Reviewing them may help avoid an unnecessary repeat test.
Frequently Asked Questions for Dr. Aksoy
When can I have sex and try to conceive after HSG?
I generally recommend avoiding sex for the first 24–48 hours after HSG, and waiting for any bleeding or pain to settle. If the procedure went smoothly and no tubal problem preventing pregnancy was found, you can try to conceive in the same menstrual cycle; there is no need to wait until the following month. If I suspect infection, or there is significant pain or a complication during the procedure, I assess that first.
How long can bleeding last after HSG, and when should I contact you?
Light spotting or a few drops of blood after HSG is normal and usually settles on its own within a day or two. I ask patients to contact me if bleeding increases, becomes as heavy as a period, or lasts more than a few days. Fever, foul-smelling discharge or worsening pelvic pain are reasons not to wait; they may indicate a complication such as infection.
How do you plan pain relief or anaesthesia before HSG?
I first ask about sensitivity to pain, previous gynaecological examinations and worries about the procedure. As HSG is usually brief, a suitable painkiller beforehand can be enough for many patients; we also discuss local anaesthetic options when needed. For someone who has had a very painful procedure, has marked anxiety, or is expected to have a technically difficult examination, we may also consider sedation. What matters to me is helping the patient go through the procedure as comfortably as possible, rather than accepting pain as something she simply has to endure.
These answers were provided by Dr. Aksoy on 31 October 2026 and describe his clinical approach. His use of a painkiller in an individual care plan is distinct from the limited trial evidence for routine oral painkillers. See the Cochrane review and ACOG guidance.
FAQ
What does HSG stand for?
Hysterosalpingography. The parts of the word describe the test: hystero means uterus, salpingo means fallopian tube, and graphy means imaging. Some clinics call it a tubal patency test or a uterotubal X-ray.
Is an HSG a treatment for blocked tubes?
Its main purpose is diagnosis, not repairing a blocked tube. Oil-soluble contrast may have a fertility benefit in selected groups, but the evidence has limits.
How long does an HSG take?
The imaging itself usually takes a few minutes. Plan for the whole appointment to take longer because it also includes preparation, positioning and a short period of rest afterwards.
When in my cycle should the test be booked?
Usually after bleeding has finished and before ovulation; the centre confirms the exact day for your cycle. The timing avoids blood obscuring the images and reduces the chance that an early pregnancy is present.
Can an HSG detect endometriosis?
No. An HSG images the uterine cavity and the channel inside each tube. Endometriosis affects tissue outside these spaces. HSG cannot diagnose or exclude the condition.
Does a normal HSG mean my tubes are fine?
It shows that contrast passed through the tubes. It does not test every function of the tubes or exclude every form of tubal disease. See what HSG can show.
Why did the test show a blockage when a later test did not?
Spasm where the tube joins the uterus can prevent contrast passing on the day, producing the appearance of a blockage in a tube that is actually open. This is one reason a single abnormal finding is often rechecked before any surgical decision is made.
Sources
- Babandi RM, Agboghoroma OC, Durojaiye KW, Jimoh KO, Essiet EA. Pain relief for hysterosalpingography: a randomized controlled, double blinded trial comparing suppository diclofenac, prilocaine/lignocaine (EMLA) cream and placebo. West Afr J Med. 2021;38(12):1174–1182. PubMed
- Hindocha A, Beere L, O’Flynn H, Watson A, Ahmad G. Pain relief in hysterosalpingography. Cochrane Database Syst Rev. 2015;(9):CD006106. PubMed · doi:10.1002/14651858.CD006106.pub3
- Swart P, Mol BW, van der Veen F, van Beurden M, Redekop WK, Bossuyt PM. The accuracy of hysterosalpingography in the diagnosis of tubal pathology: a meta-analysis. Fertil Steril. 1995;64(3):486–491. PubMed · doi:10.1016/S0015-0282(16)57781-4
- ASRM Practice Committee. Fertility evaluation of infertile women: a committee opinion (2026). ASRM
- Wang R, Watson A, Johnson N, Cheung K, Fitzgerald C, Mol BWJ, Mohiyiddeen L. Tubal flushing for subfertility. Cochrane Database Syst Rev. 2020;10(10):CD003718. PubMed · doi:10.1002/14651858.CD003718.pub5
- Dreyer K, van Rijswijk J, Mijatovic V, et al. Oil-based or water-based contrast for hysterosalpingography in infertile women. N Engl J Med. 2017;376(21):2043–2052. PubMed · doi:10.1056/NEJMoa1612337
- Huijser J, Zhu Q, Kamphuis D, et al. Oil-based versus water-based contrast media during hysterosalpingography for infertility (H2Oil2 study): a randomised controlled trial. SSRN preprint, posted 17 June 2026. SSRN · doi:10.2139/ssrn.6942897 — preprint; not yet peer reviewed.
- Li R, Chen W, Liu Y, Ma L, Qiu L, Han J, Li R. The impact of preconceptional hysterosalpingography with oil-based contrast on maternal and neonatal iodine status. Reprod Sci. 2021;28(10):2887–2894. PubMed · doi:10.1007/s43032-021-00640-0
- Geenen RWF, van der Molen AJ, Dekkers IA, et al. Contrast media for hysterosalpingography: systematic search and review providing new guidelines by the Contrast Media Safety Committee of the European Society of Urogenital Radiology. Eur Radiol. 2024;34:6435–6443. Springer · doi:10.1007/s00330-024-10707-6
- Guerbet. Lipiodol Ultra Fluid: UK Summary of Product Characteristics (PL 12308/0022). Revised 17 March 2021. Product information
- ASRM Practice Committee. Role of tubal surgery in the era of assisted reproductive technology: a committee opinion (2021). ASRM
- ASRM. Hysterosalpingogram (HSG). Patient education fact sheet. Revised 2023. ASRM patient information.
- ACOG. Pain Management for In-Office Uterine and Cervical Procedures. Clinical Consensus. May 2025. ACOG.
- van Rijswijk J, van Welie N, Dreyer K, Tajik P, Lambalk CB, Hompes P, Mijatovic V, Mol BWJ, Zafarmand MH. Tubal flushing with oil- or water-based contrast medium: can we identify markers that indicate treatment benefit? Hum Reprod Open. 2019;2019(3):hoz015. Full article · PubMed · doi:10.1093/hropen/hoz015
- Rosielle K, Kamphuis D, van Welie N, et al. Oil-based versus water-based contrast media for hysterosalpingography in infertile women of advanced age, with ovulation disorders or a high risk for tubal pathology: study protocol of a randomized controlled trial (H2Oil2 study). BMC Womens Health. 2022;22:123. PubMed · doi:10.1186/s12905-022-01707-z
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